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Chapter 8 Advising Travelers with Specific Needs

Wilderness & Expedition Medicine

Christopher Van Tilburg

Wilderness and expedition trips are a unique aspect of travel because of challenging terrain, extreme weather, remote locales, and long durations. Popular destinations include trekking to Everest Base Camp, climbing Mount Kilimanjaro, hiking the Inca Trail, sailing the South Pacific, and exploring the poles. Adventure travel often includes mountaineering, backpacking, cycling, diving, surfing, or river rafting. Travelers may be working, providing humanitarian relief, or completing scientific research.

The risks and consequences of injury and illness are often significantly increased in wilderness and expedition travel compared with other types of travel for several reasons:

  • Destinations may be remote and lack access to care.
  • Communication is often limited.
  • Weather, climate, and terrain can be extreme.
  • Travelers exert themselves physically, increasing caloric, fluid, and sleep requirements.
  • Trips are often long: several weeks, months, or years.
  • Expeditions are often goal oriented, which can cause travelers to exceed safety limits.

PRETRAVEL CONSIDERATIONS

In addition to routine travel medicine advice, providers should gather extra information and discuss precautions for wilderness and expedition travel.

Trip Type

Obtain details about the type, length, and remoteness of the trip. Guided trips may eliminate some of the need for complex logistics planning on the part of the traveler. However, participants in guided trips should ask key questions of the trip organizers including:

  • Guide experience
  • Type of medical kit carried by guides
  • Contingency plan for emergencies
  • Recommended medications and medical supplies to be carried by participants
  • Type of insurance recommended
  • Medical training of guides

In a few cases, such as polar cruises and Mount Everest expeditions, a formal medical officer with a comprehensive medical kit may be available.

Confirm if the skill level of the participant matches the trip type: beginners in an activity such as diving, mountaineering, skiing, or sailing should participate in instructional trips. Those with less experience or visiting a location for the first time should be encouraged to go on a guided trip. Most people will consult a travel medicine professional only after they have selected and paid for their adventure, but it may be possible to work with the organizer to change it to a trip more in line with the traveler’s skill and experience.

For self-planned trips, the travel medicine practitioner may need to augment a comprehensive medical kit with prescription medication and offer more support with logistics, evacuation planning, and insurance.

Personal Health Requirements

Adequate nutrition, hydration, and sleep may be difficult to obtain, especially with increased demand because of weather, terrain, and exertion. Travelers should pay attention during the planning stages to how food and water will be obtained on the journey.

Pretravel screening should be completed for conditions that can be exacerbated by high altitude, extreme heat, extreme cold, exertion, and other environmental hazards. These include diabetes (particularly insulin-dependent diabetes), asthma, any cardiac disease (such as hypertension, arrhythmias, and coronary artery disease), chronic pain treated with opiates, recent surgery, anaphylaxis-level allergy, oxygen-dependent emphysema, and sleep apnea. Travelers who have battery-operated devices, such as a continuous positive airway pressure machine or an insulin pump, should be cautioned about device failure and have a backup plan. A past history of environmental illness—altitude illness, hypothermia, frostbite, heat exhaustion, or anaphylaxis—likely puts one at increased risk for recurrence.

Medical clearance for participation may be required for a guided trip. The treating physician should complete medical clearance for travelers with chronic disease. Travel health practitioners can complete pretravel medical clearance if it is a usual function of their practice and the patient has no chronic disease or medications. If possible, travelers should get medications for chronic illness from the treating physician. For example, travelers with preexisting asthma should obtain their routine, rescue, and emergency self-treatment medications from the treating physician.

Money and Insurance

Rescue, evacuation, and repatriation may require upfront payment, especially with aeromedical transport from remote locations. Travelers should bring sufficient emergency cash and a credit card with high credit and cash advance limits.

Insurance is widely variable and comes in many forms, but insurance does not guarantee rescue. Insurance may be contingent on limits including preexisting conditions, deductibles, maximum expenditures, and medical control approval. Insurers may also not authorize helicopter or air-planes for in-country transport or repatriation. Insurance companies may deny claims involving chronic illness, drugs, alcohol, pregnancy, mental health, and acts of war or civil unrest.

Types of insurance include:

  • Domestic health insurance, which may or may not be effective outside a home country.
  • Travel insurance, which often includes medical, trip cancellation, evacuation, and repatriation benefits, but may exclude coverage for wilderness rescue and adventure sports like mountaineering, skiing, and diving. An adventure sports rider is available with some travel insurance policies, so travelers should confirm coverage for adventure sports.
  • Wilderness rescue insurance (usually separate from travel insurance), such as policies through North American mountaineering clubs, outdoor and professional associations, and scuba dive organizations. Short-term rescue insurance is available in some countries, for example, through local helicopter rescue companies, ski resorts, and guides.
  • Comprehensive expedition policies, including travel, medical, rescue, security, and repatriation services.

Training

If travelers have time before disembarking, they should consider completing a first aid and basic life support course. Such courses can be found through local community colleges and fire departments.

Emergency Resources

Before they go, travelers should know emergency escape routes, local rescue resources, embassy contacts, and local medical facilities.

If travel medicine practitioners are willing to accept phone calls, emails, and text messages from travelers who are abroad, give out contact information and approximate time of response. Make sure travelers understand this is not a substitute for local emergency care.

In a travel medicine encounter, physicians may only have a brief moment to educate travelers. Depending on the type, duration, and location of trip, a few key pearls may be worth discussing:

  • Travelers should understand basic wound care, seek help with signs of infection— redness, swelling, pus, and warmth—and be educated on self-treatment with antibiotics.
  • For hypothermia, cessation of shivering and mental status changes are dangerous signs. Frostbite can be treated with thrombolytics to aid reperfusion, but treatment needs to be initiated within 72 hours in a hospital (see Chapter 2, Problems with Heat & Cold).
  • Heat stroke marked by a temperature of 40°C and mental status changes is a medical emergency.
  • Snakes, spiders, scorpions, ticks, and jellyfish can deliver toxic venom, inoculate microbes, and cause anaphylaxis. For anaphylaxis (also caused by food), treatment with epinephrine can be life-saving if administered immediately. Regional antivenoms exist around the world for certain venomous snakes, spiders, scorpions, and jellyfish.
  • Travel to high altitude may require prevention and treatment with acetazolamide, dexamethasone, and other medications. Mental status changes and ataxia are ominous signs of high-altitude cerebral edema. Breathlessness at rest is the sign of life-threatening high-altitude pulmonary edema.

WILDERNESS SUPPLIES

Communication and Route Finding

Travelers should carry a cell phone enabled with global positioning system (GPS), such as a smart-phone. Importantly, not all North American cell phones are compatible with international networks. Travelers should check with their cell carrier before departing.

In many countries, a global-compatible phone can be used with an international plan purchased beforehand through the traveler’s North American cell carrier. Global-compatible phones use the Global System for Mobiles system commonly found with AT&T and T-Mobile services. Phones that use the Code Division Multiple Access system, such as Sprint, Verizon, and US Cellular services, often do not work internationally.

Alternatively, an unlocked (not restricted to any carrier) global-compatible cell phone can be used with a local SIM card in the country of travel. If one does not have a global-compatible phone and SIM card capability, travelers can buy an inexpensive local phone, which is best for travelers who expect frequent use of their phone, especially for data and local calls. Phones and SIM cards are usually available at kiosks and stores in major cities and in some airports. In some countries, registration to obtain a local SIM card requires fingerprinting and a passport picture.

Where cell phone service is not available, travelers may consider an unlocked (no frequency restrictions) VHF/UHF radio or a satellite phone. Advise travelers that restrictions exist and permits are required in many countries regarding use of handheld radios and satellite phones; they should check local restrictions prior to departing.

Remind travelers that electronics are not foolproof; often they are limited by battery power, dense cloud cover, deep canyons, government restrictions, and physical damage caused by impact, water, or extreme temperatures. A backup power source, such as a solar or dynamo charger, is useful.

For extreme terrain and remote locations, adventurers should carry and know how to use a GPS unit (or have GPS app installed on their phone), compass, altimeter, or local topographic map (the latter may need to be acquired in-country).

Clothing

Remind travelers that clothing helps prevent heat and cold illness as well as bites and stings from insects and arthropods.

Cold weather clothing should be polyester, nylon, Merino wool, or, in some circumstances, goose down. Layering typically consists of a base layer, insulating layers of heavy-pile polyester or nylon-encased polyester (goose down suffices if traveling to a location that is dry and cold), and a windproof, waterproof outer layer of tightly woven nylon with a durable water-repellent coating. Gloves, hat, neck warmer, warm socks, and goggles are vital to cover all exposed skin.

For hot weather, sun- and insect-protective clothing is important including loose-fitting, lightweight clothing made from nylon, polyester, or a cotton blend. Long-sleeve shirts and long pants offer the most protection. A wide brim sun hat and a bandana protect the head and neck. Sunglasses protect eyes. Clothing should be sprayed with permethrin to ward off insects and arthropods. Footwear should be activity-specific boots or shoes, equally important in a marine or mountain environment.

Emergency Kits

Expedition and wilderness adventures often require a comprehensive, yet compact, personal emergency kit for survival, medical care, and equipment repair. In addition to a basic travel health kit (see Chapter 2, Travel Health Kits), travelers should consider packing additional items due to the remote nature of their travel. Items may include additional first aid supplies (such as a pocket-size CPR mask), safety supplies, and a more robust variety of medications (see below). Standard kits may also need to be augmented for specific activities like undersea, ocean, jungle, polar, and high-altitude travel.

If travelers are on guided trips, they may only need a small personal medical kit. A list of recommended supplies and drugs, including antibiotic, analgesic, and anaphylaxis medications, should be available from the guide company and will likely need to be prescribed at the travel medicine encounter. Before they go, travelers should identify any available group emergency equipment such as an automatic external defibrillator, a portable stretcher, portable hyperbaric chamber, oxygen, and comprehensive medical kit.

Be cautious if asked to prescribe medications for guides to be stocked in the expedition medical kit intended for use on clients. Third-party use of prescription medication is unlawful in most jurisdictions and best left for the guide company medical director. If prescribing to a guide as a patient, clarify that the medication is for the guide’s personal use.

MEDICATIONS

Travelers should be advised on self-treatment of disease such as gastroenteritis, febrile illness, wound infections, and respiratory illness. This may require prophylactic and self-treatment with antibiotics. In addition to medications recommended in a basic travel health kit (see Chapter 2, Travel Health Kits), travelers should consider a more comprehensive medication supply including opiate pain medication, ophthalmologic antibiotic ointment and anesthetic, and nondrowsy antihistamines.

SAFETY SUPPLIES

Wilderness and expedition travelers should consider packing additional safety equipment to supplement a travel health kit. These items can help in an emergency situation. Useful items include the following:

  • Headlight with extra batteries
  • Perlon cord
  • Emergency sleeping sack or tarp
  • Duct tape
  • Multi-tool
  • Safety pins
  • Polyurethane straps
  • Chemical heat packs
  • Map, compass, altimeter
  • Whistle
  • Water purification tablets
  • Oral hydration packs

BIBLIOGRAPHY

  1. Iserson KV. Medical planning for extended remote expeditions. Wilderness Environ Med. 2013 Dec;24(4):366–77.
  2. Lewin M, Jensen S, Platts-Mills T. Wilderness preparation, equipment, and medical supplies. In: Auerbach PS, editor. Wilderness Medicine. 6th ed. Philadelphia: Elsevier; 2012. pp. 1820–44.
  3. Lipman GS, Eifling KP, Ellis MA, Gaudio FG, Otten EM, Grissom CK. Wilderness Medical Society practice guidelines for the prevention and treatment of heat-related illness: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S55–65.
  4. McIntosh SE, Opacic M, Freer L, Grissom CK, Auerbach PS, Rodway GW, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S43–54.
  5. Mellor A, Dodds N, Joshi R, Hall J, Dhillon S, Hollis S, et al. Faculty of Prehospital Care, Royal College of Surgeons Edinburgh guidance for medical provision for wilderness medicine. Extrem Physiol Med. 2015;4:22.
  6. Quinn RH, Wedmore I, Johnson EL, Islas AA, Anglim A, Zafren K, et al. Wilderness Medical Society practice guidelines for basic wound management in the austere environment: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S118–33.
  7. Zafren K, Giesbrecht GG, Danzl DF, Brugger H, Sagalyn EB, Walpoth B, et al. Wilderness Medical Society practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S66–85.
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